Healthcare Provider Details

I. General information

NPI: 1568729978
Provider Name (Legal Business Name): PEDIATRIC THERAPY EXPERTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 NELA AVE
BELLE ISLE FL
32809-6170
US

IV. Provider business mailing address

2509 NELA AVE
BELLE ISLE FL
32809-6170
US

V. Phone/Fax

Practice location:
  • Phone: 407-451-9871
  • Fax: 407-704-3955
Mailing address:
  • Phone: 407-451-9871
  • Fax: 407-704-3955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberSA5261
License Number StateFL

VIII. Authorized Official

Name: MS. LORI K MITNIK
Title or Position: PRESIDENT/OWNER
Credential: MA, CCC-SLP
Phone: 407-451-9871